Methods of transvascular retrograde access placement and devices for facilitating the placement

ABSTRACT

A system for providing transvascular retrograde access in a central blood vessel of a patient. In some embodiments, the system has a handle; a catheter extending from the handle; and a tissue piercing element extending from the handle through the catheter, the tissue piercing element having a sharp distal tip adapted to extend from a distal portion of the catheter, the catheter and handle being adapted to be separated from the tissue piercing element, a distal portion of the tissue piercing element being adapted to serve as a guide for introduction of a device into the central blood vessel. The invention also includes a method of providing transvascular retrograde access to a central blood vessel of a patient.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims the benefit under 35 USC 119 to U.S. ProvisionalApplication No. 61/235,952, filed Aug. 21, 2009, the disclosure of whichis incorporated by reference as if fully set forth herein.

FIELD OF THE INVENTION

The present invention relates to methods and devices directed towardproviding transvascular retrograde access placement in central vessels.More particularly, these methods and devices direct an initial passageof a needle tipped guidewire from the inside of the vessel to theoutside, followed by guided insertion of a secondary catheter over theneedle tipped guidewire into the vessel.

INCORPORATION BY REFERENCE

All publications, patents and patent applications mentioned in thisspecification, either by an inventor common to this application or byother inventors, are herein incorporated by reference to the same extentas if each individual publication, patent, or patent application wasspecifically and individually indicated to be incorporated by reference.

BACKGROUND OF THE INVENTION

Gaining direct access by way of a catheter to a central vein (one whichgoes directly to the heart) is a common procedure that is useful for anumber of medical needs, including providing fluids and nutrition,administering drugs, and allowing access to the heart for cardiovascularmeasurements or the implantation of devices such as pacemakers.Conventional approaches for performing central venous catheterization,as shown in FIG. 1, generally involve the placing of catheters, needlesand/or wires through a percutaneous entry site 1 into a jugular vein 14or a subclavian vein 16 and subsequent central venous cannulation. Thismethod involves inherent risks with potentially serious consequences andadverse effects to the patient due to the technique's essentially blindpuncture through the skin and percutaneous tissue (i.e., from theoutside of the skin to the inside of the central vein) overlaying anaccessible site of the vein. More specifically, conventional techniques,with or without fluoroscopic guidance, involve percutaneous puncture ofeither the jugular or subclavian vein with a hollow needle, and thepassage of a guidewire into the punctured vein through the needle.Thereafter, the guidewire assists with the insertion of a vascularcatheter, which then ultimately replaces the guidewire. Theses centralveins are deep structures, and cannot be visualized without imagingtechnology. The percutaneous puncture site generally is determined byanatomic landmarks (“dead reckoning”) or, less commonly, with the aid oftranscutaneous ultrasound.

While this conventional technique is usually accomplished with few orany complications and minimal pain to the patient, the technique, due tothe essentially blind percutaneous puncture, inherently carriessignificant risks. These risks include potentially disabling orlife-threatening injuries such as injury to adjacent vascular structuresor nerves, occurrence of stroke secondary to vascular injury, oroccurrence of pneumothorax or hemothorax secondary to lung injury. Therisk of eventualities such as these are more likely when the techniqueis performed on children or on adult patients with challenging anatomyor conditions, such as emaciation or morbid obesity.

Safer and more cost-efficient alternative approaches to central veinaccess that obviate the need for blind percutaneous vein puncture wouldbe a welcome addition to the possible approaches available to patientsrequiring central vein access. One such possible safer and morecost-efficient approach may include accessing the central blood vesselvia a transvascular retrograde approach. The approach may be facilitatedby devices and methods that provide accurate and controlled manipulationwithin the central blood vessel and while exiting the central bloodvessel.

Reference is also made to U.S. application Ser. No. 12/366,517, entitled“Methods of Transvascular Retrograde Access Placement and Devices forFacilitating Therein”, filed Feb. 5, 2009; which is acontinuation-in-part of U.S. application Ser. No. 11/424,131, entitled“Methods of Transvascular Retrograde Access Placement and Devices forFacilitating Therein”, filed Jun. 14, 2006; which is a continuation ofU.S. application Ser. No. 11/381,229, filed May 2, 2006; all of whichare incorporated by reference as if fully set forth herein.

SUMMARY OF THE INVENTION

Methods for performing transvascular retrograde access placement in acentral blood vessel should be safe, accurate, and controlled. It isdesirable that the methods, and the devices that facilitate them,include accurately positioning a portion of a vascular device, such asan angled catheter tip, into a desired position within a vessel. Oncethe portion of the device is positioned accurately within the vessel, itis desirable that a portion of the device or system, such as a needletipped guidewire, may be moved through the device and/or through thevessel in a safe and controlled manner, such that it may exit the vesselin a safe and controlled manner.

Described herein are devices, systems and methods for performingtransvascular retrograde access placement in a central blood vessel in asafe, accurate, and controlled manner. In general, the devices mayinclude a catheter comprising an angled tip; a handle coupled to thecatheter, the handle having a reference portion, wherein the position ofthe reference portion corresponds to the position of the angled tip; alocking mechanism, coupled to the handle, sized and configured to coupleto a needle tipped guidewire; and a slider, coupled to the handle, sizedand configured to advance the needle tipped guidewire through thecatheter. In general, the methods may include positioning a catheter ofa vascular device, the catheter comprising an angled tip, within thecentral blood vessel such that the angled tip faces a desired exit siteon a wall of the central blood vessel and passing a needle tippedguidewire from the catheter through the desired exit site on the wall ofthe central blood vessel and skin of the patient.

One aspect of the invention provides a system for providingtransvascular retrograde access in a central blood vessel of a patient.In some embodiments, the system includes a handle; a catheter extendingfrom the handle; and a tissue piercing element extending from the handlethrough the catheter, the tissue piercing element comprising a sharpdistal tip adapted to extend from a distal portion of the catheter, thecatheter and handle being adapted to be separated from the tissuepiercing element, a distal portion of the tissue piercing element beingadapted to serve as a guide for introduction of a device into thecentral blood vessel. The distal end of the catheter may have an angledtip, and in some such embodiments the system may have a reference at aproximal end of the catheter indicating a bending direction of theangled tip.

In some embodiments, the handle comprises an actuator adapted to advancethe tissue piercing element through an opening at the distal end of thecatheter. The actuator may include a slider adapted to move within aslot in the handle. Alternatively or additionally, the actuator mayinclude a spring and possibly a spring release element and/or aninterlock having a first state adapted to prevent actuation of theactuator and a second state adapted to permit actuation of the actuator.The system may also have a lock having a first state adapted to preventmovement of the tissue piercing element with respect to the actuator anda second state adapted to permit movement of the tissue piercing elementwith respect to the actuator.

In some embodiments, the handle has a deflection actuator adapted todeflect a distal tip of the catheter away from a longitudinal axis ofthe catheter. In such embodiments the handle may also have a deflectionindicator adapted to indicate an amount of deflection of the distal endof the catheter. Some embodiments of the system may also have aninterlock adapted to prevent movement of the sharp tip of the tissuepiercing element out of the distal portion of the catheter unless thedistal portion of the catheter is deflected away from a longitudinalaxis of the catheter.

Another aspect of the invention provides a method of providingtransvascular retrograde access to a central blood vessel of a patient.Some embodiments of the method include the steps of inserting a distalend of a catheter into a blood vessel other than the central bloodvessel, a proximal end of the catheter being connected to a handledisposed outside of the patient; advancing the distal end of thecatheter into the central blood vessel; orienting the distal end of thecatheter to an exit location within the central blood vessel; actuatinga tissue piercer actuator of the handle to advance a tissue piercingelement from the catheter through the central blood vessel at the exitlocation; and introducing a device over the tissue piercing elementthrough the exit location into the central blood vessel.

In some embodiments, the orienting step includes the step of rotatingthe catheter with respect to the patient, such as by rotating the handleand catheter together. In some embodiments, the orienting step includesthe step of bending the distal end of the catheter with respect to alongitudinal axis of the catheter, such as by moving a bending actuatorof the handle. In such embodiments, the method may also include the stepof preventing actuation of the tissue piercer actuator if catheterdistal end is not bent.

In some embodiments, the step of actuating the tissue piercer includesthe step of sliding the tissue piercer actuator within a slot in thehandle. In some embodiments, the step of actuating the tissue piercerincludes the step of releasing a spring within the handle, such as byactuating a spring release element to release the spring.

Some embodiments of the method include the step of actuating a springrelease element to release the spring. In some embodiments, the methodincludes the step of locking the tissue piercing element to the tissuepiercer actuator prior to actuating the tissue piercing actuator.

The invention will be explained in more detail below with reference tothe drawings.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 shows a conventional technique of the prior art of performingupper trunk central venous catheterization.

FIG. 2 shows a vascular sheath inserted into a femoral vein of thecentral venous system of a patient.

FIG. 3 shows a general use guidewire passed through a femoral venousvascular sheath and the venae cavae to a jugular vein.

FIG. 4 shows an angled-tip vascular catheter passed over a general useguidewire and to a jugular vein.

FIG. 5 shows an embodiment of a needle-tipped guidewire of the presentinvention inserted, via the femoral venous vascular sheath, through theangled-tip vascular catheter and used to puncture the wall of thejugular vein.

FIG. 6A shows a secondary vascular catheter being passed over the stiffintravascular guidewire, now outside the body, in a retrogradedirection, from the distal end of the guidewire toward the proximal end.In some embodiments of the method, the penetrating device is removedfrom the distal end of the guidewire at this point.

FIG. 6B shows the secondary vascular catheter entering the jugular veinin a retrograde direction, in the direction of venous blood flow, overthe stiff intravascular guidewire.

FIG. 6C shows the secondary vascular catheter in place in the jugularvein and positioned to act as a vascular access port, the stiffintravascular guidewire having been withdrawn from the jugular vein,ultimately to exit through its femoral vein site of entry.

FIG. 6D shows the secondary vascular catheter in place in the jugularvein as a vascular access port, and as an example of use, a syringecentrally administering drug through the central vein access port.

FIGS. 7A-7F show an embodiment of a method that makes use catheter withan angled tip, with a focus on the activity that occurs at the site ofexit from the jugular vein and re-entry there into. FIG. 7A shows theapproach of a general use guidewire to the vicinity of a desired exitsite in a jugular vein.

FIG. 7B shows the approach of a vascular catheter over a general useguidewire to the vicinity of the desired exit site in the jugular vein.

FIG. 7C shows the angled-tip vascular catheter with the general useguidewire having been withdrawn and a stiff guidewire with a penetratingdevice on its distal end being advanced to the distal end the curved tipvascular catheter.

FIG. 7D shows the angled vascular tip catheter rotating toward a desiredexit site on the wall of the jugular vein, the site of exit on anexterior facing aspect of the vein, the rotation being driven by torqueapplied at the proximal end of the catheter.

FIG. 7E shows the penetrating device mounted on the distal end of thestiff guidewire advancing out of the vascular catheter, and penetratingoutwardly through the wall of the jugular vein into neck muscle andsubcutaneous tissue.

FIG. 7F shows the penetrating device penetrating further outward throughthe skin of the neck and from the body, the stiff intravascularguidewire trailing behind. (Hereinafter, the method proceeds as depictedin FIGS. 6A-6D.)

FIG. 8 shows an embodiment of the method wherein an angled catheterenters the vascular system through an antecubital vein and is advancedto a desired exit site in the jugular vein, where a tissue-penetratingdevice is delivered through the catheter to form a pass-though intowhich a retrograde jugular vein access device may be placed.

FIG. 9A shows an embodiment of a vascular device having an angled tipcatheter and a handle having a slider, a reference portion, and alocking mechanism.

FIG. 9B shows a larger view of the handle of FIG. 9A having a slider anda reference portion.

FIG. 9C shows a larger, exploded view of the locking mechanism of thehandle of FIG. 9C.

FIGS. 10A and 10B show an embodiment of a system having a needle tippedguidewire and a vascular device having an angled tip catheter and ahandle having a slider, a reference portion, and a locking mechanism.

FIG. 11 shows an embodiment of a needle tipped guidewire that may beinserted into a vessel through the angled-tip vascular catheter and usedto puncture the wall of a vessel.

FIGS. 12A-D show yet another embodiment of a system for providingtransvascular retrograde access in a central blood vessel of a patient.

DETAILED DESCRIPTION OF THE INVENTION

Described herein are devices, systems and methods for performingtransvascular retrograde access placement in a central blood vessel in asafe, accurate, and controlled manner. In general, the devices mayinclude a catheter comprising an angled tip; a handle coupled to thecatheter, the handle having a reference portion, wherein the position ofthe reference portion corresponds to the position of the angled tip; alocking mechanism, coupled to the handle, sized and configured to coupleto a needle tipped guidewire; and a slider, coupled to the handle, sizedand configured to advance the needle tipped guidewire through thecatheter. In general, the methods may include positioning a catheter ofa vascular device, the catheter comprising an angled tip, within thecentral blood vessel such that the angled tip faces a desired exit siteon a wall of the central blood vessel and passing a needle tippedguidewire from the catheter through the desired exit site on the wall ofthe central blood vessel and skin of the patient.

Embodiments of a method of the transvascular retrograde accessplacement, as provided herein, include the puncturing of a central bloodvessel from the inside of the vessel with a penetrating device, such asa needle tipped guidewire or other similarly configured device, andexiting that penetrating device from a patient through the skin. By suchan inside-to-outside approach, the ability of a surgeon to preciselydetermine the location of a pass-through site in the vascular wall issubstantially enhanced over prior art methods that rely on aconventional outside-to-inside approach, as shown in FIG. 1. After thepenetrating device penetrates through the skin to the exterior of thebody, a vascular catheter may be inserted into the central blood vesselby passing the catheter over the penetrating device in a retrogradedirection.

The devices, systems, methods, and any combination thereof forperforming transvascular retrograde access placement in a central bloodvessel described herein provide at least the following advantages.First, they may be safer and pose less risk to the patient. Furthermore,as described herein, the methods, and the devices that facilitate them,include accurately positioning a portion of a vascular device, such asan angled catheter tip, into a desired position within a vessel. Oncethe portion of the device is positioned accurately within the vessel, asecond portion of the device or system, such as a needle tippedguidewire, may be moved through the device and/or through the vessel ina safe and controlled manner, such that it may exit the vessel in a safeand controlled manner.

Embodiments of the method and devices for implementing the method aredirected toward various regions of the vascular system, in accordancewith particular medical indications. One particular use of the methodsof the invention is for central vein access, in which a central vein,such as a jugular vein or subclavian vein is accessed. The initialapproach to the central vein, by way of a guidewire, followed by avascular catheter, is by way entry into a primary vein, such as femoralvein or antecubital vein. Thereafter, a penetrating element, positionedby advancement from the primary vein site of entry to a desired site ofexit in the central vein, creates an opening through the vessel wall andoverlaying skin. That site of exit, in turn, becomes the site ofre-entry for a central vein catheter. Inasmuch as what is initiallyformed as an exit site from the vessel can later be used as a site forentry for a central vein catheter, the site of opening/entry may also beneutrally referred to as a vascular pass-through site.

Embodiments of the invention, while generally described and depictedherein in the context of providing retrograde access into a central veinthrough an opening originally formed as an exit from the central vein,the invention may also be generally understood as providing methods ofvascular entry through an exit-formed opening in blood vessels otherthan a central vein. This method embodiment includes positioning avascular catheter within a blood vessel such that a portion of thevascular catheter faces a desired exit site on a wall of the bloodvessel, passing a penetrating device that is advanced from the vascularcatheter through the desired exit site on the wall of the blood vesseland a skin site of the patient overlaying the desired exit site, andpassing an end of a secondary vascular catheter through the exit siteand into the blood vessel. In various embodiments of this method, theblood vessel may be a vein, a central vein, or an artery. An example ofan artery that is particularly difficult to access externally is thesubclavian artery, thus there may be advantages to accessing thesubclavian artery by such methods as described herein.

The primary blood vessel cannulation may be achieved by means of theModified Seldinger Technique, wherein the desired vessel or cavity ispunctured with a sharp hollow needle; a round-tipped guidewire is thenadvanced through the lumen of the needle, and the needle is withdrawn.An introducer is then inserted over the round-tipped guidewire, and intothe vessel; a “sheath” or blunt cannula is passed through theintroducer; and the guidewire and introducer are then withdrawn. Thesheath can then be used to introduce catheters into the vessel.

In accordance with the methods of the present invention, the ModifiedSeldinger Technique typically is performed with an 18-gauge hollowneedle about 2⅞ inches in length, and a 5 cc syringe secured to the endof the 18-gauge needle opposite of the needle-tip. As shown in FIG. 2, afemoral vein 12 may be percutaneously cannulated with the needle. Onceblood from the femoral vein 12 is aspirated into the syringe, thesyringe is removed while the needle is held in place. Through thisneedle, a short guidewire, such as a J-tip wire measuring about 0.035inches in diameter and about 20 centimeters in length may be advanced upthe femoral vein 12 and into the iliac vein. The needle is then removedwhile the short guidewire is held in place. Thereafter, as shown in FIG.2, a vascular sheath 20, generally measuring about 10 centimeters inlength and typically but not necessarily including a removable stiffintroducer and a hemostatic valve, is advanced over the short guidewireand into the femoral vein 12. The vascular sheath 20 is typically a 5French (F) sheath, but may be a 6 F or a 4 F sheath, or anothersimilarly sized and configured sheath. (French/3.14=inner diameter of asheath or catheter in millimeters).

Then, with the vascular sheath 20 being substantially introduced intothe patient, the short guidewire and the stiff introducer are removedand the vascular sheath 20 may be flushed by inserting heparinizedsaline solution into the vascular sheath 20 through the hemostaticvalve. In various embodiments of the methods of the present invention,the Modified Seldinger Technique may be performed with other similarlysized and configured needles, syringes, sheaths, and/or wires.

Thereafter in furtherance of embodiments of the method, as shown in FIG.3, a general use guidewire 30 typically measuring about 0.035 inches indiameter may be passed through the vascular sheath 20 and ultimatelypositioned in a jugular vein 14 in the vicinity of a desired exit andreentry site (or pass-through site) for central vein access. Followingthe insertion and positioning of the general use guidewire 30, aninventive angled-tip vascular catheter 40 may be passed over the generaluse guidewire 30, as shown in FIG. 4, after which the general useguidewire 30 is removed.

Continuing with embodiments of the method, as shown in FIG. 4, thevascular catheter 40 may then be positioned in the jugular vein 14 withthe angled-tip 42 facing the interior wall 15 of the jugular vein 14 ata desired exit site 25. As depicted in FIG. 5, once the vascularcatheter 40 is properly positioned, under continuing diagnostic imaging,as in some embodiments, a needle or other similarly configuredsharp-tipped device or otherwise penetrating device, such as aneedle-tip portion 52 of a stiff intravascular tissue-penetratingguidewire 50, may be passed through the end of the angled-tip 42 of thevascular catheter 40 and further pass through or penetrate the wall 15of the jugular vein 14. Thereafter, the vascular wall penetrating devicesuch as the needle, or the needle-tip portion 52 and a length of theneedle-tipped guidewire 50 are passed through the subcutaneous tissueand exited through the skin of the patient (typically at mid-neck areawhen the central blood vessel punctured is a jugular vein 14) where theyare recovered and pulled above the surface of the skin, as shown in FIG.5. The vascular catheter 40 may then be removed from the vascular systemof the patient, leaving the needle-tipped guidewire 50 in position.

FIG. 6A shows a secondary vascular catheter 60 being passed over thestiff intravascular guidewire 50, now outside the body, in a retrogradedirection, from the distal end of the guidewire toward the proximal end.In some embodiments of the method, the penetrating device 52 is removedfrom the distal end of the guidewire 50 at this point.

FIG. 6B shows the secondary vascular catheter 60 entering the jugularvein 14 in a retrograde direction (in the direction of venous bloodflow) over the stiff intravascular guidewire 50. FIG. 6C shows thesecondary vascular catheter 60 in place in the jugular vein 14 andpositioned to act as a vascular access port, the stiff intravascularguidewire having been withdrawn from the jugular vein, ultimately toexit through its femoral vein site of entry. FIG. 6D shows the secondaryvascular catheter 60 in place in the jugular vein 14 as a vascularaccess port, and as an example of use, a syringe 75 centrallyadministering drug through the central vein access port.

FIGS. 7A-7F focus on the activity that occurs at the site of exit fromthe jugular vein and re-entry there into. FIG. 7A shows the approach ofa general use guidewire 30 to the vicinity of a desired exit site in thejugular vein. FIG. 7B shows the approach of a vascular catheter 40 overthe general use guidewire 30 to the vicinity of the desired exit site 25in the jugular vein 14. The curved or angled tip 42 of the vascularcatheter has an angle of about 45 degrees from the central longitudinalaxis of the catheter, and may be diagnostically visualizable by theradiopaque marking 43.

FIG. 7C shows the angled-tip vascular catheter 40 with the general useguidewire having been withdrawn from the catheter, and a stiff guidewire50 with a penetrating device 52 (such as a needle tip) on its distal endhaving been advanced to the distal end of the angled tip vascularcatheter. FIG. 7D shows the angled vascular tip catheter 40 rotatingtoward a desired exit site on the wall of the jugular vein. The site ofvascular exit 25 is on a body exterior-facing aspect of the vein, so thepenetrating device that eventually is expressed through the catheter isdirected toward the skin, and not internally into the neck. The rotationis being driven by torque applied by a physician to a torqueable handle49 on the catheter at its proximal end.

FIG. 7E shows the penetrating device 52 mounted on the distal end of thestiff guidewire 50 advancing out of the distal opening of the vascularcatheter and directly into the wall at the exit site 25, penetratingoutwardly through the wall of the jugular vein into neck muscle andsubcutaneous tissue. FIG. 7F shows the penetrating device penetratingfurther outward through the skin of the neck and from the body, thestiff intravascular guidewire trailing behind. Hereinafter, the methodproceeds as depicted in FIGS. 6A-6D, wherein, briefly, as thepenetrating device and attached guidewire are outside the body, asecondary vascular catheter is passed in a retrograde direction over theguidewire, through the exit site, and into the jugular vein. In anoptional step, the penetrating device may be removed from the guidewireprior to the secondary vascular catheter being passed there over. Afterinsertion of the vascular catheter, the guidewire is removed from thejugular vein, typically through its site of entry in the femoral vein,and the secondary vascular catheter remains in place as a central veinaccess port.

Other embodiments of the methods of transvascular retrograde accessplacement procedure may be performed in a central blood vessel otherthan the jugular vein, wherein the needle, the needle-tipped guidewire,or any other similar device, may exit the patient through another areaof the patient. For example, the transvascular retrograde accessplacement procedure may be performed in a subclavian vein, wherein aneedle, a needle-tipped guidewire, or other similar device exits thepatient through skin of the upper trunk just below a clavicle. In stillother embodiments of the method, a blood vessel other than a centralvein, such as a peripheral vein or an artery, may be accessed byre-entry into an opening created by outward penetration from within thevessel. The method may be particularly advantageous when external accessto the vessel is complicated by normal anatomy (such being the case withthe subclavian artery, for example), or by a complicating injury ormedical condition.

Another embodiment of the method of transvascular retrograde accessplacement varies from the previously described methods in that ratherthan approaching the central vein by way of femoral vein cannulation, anantecubital blood vein or artery (located in the antecubital fossa of anarm) is cannulated. As shown in FIG. 8, this method embodiment morespecifically includes, through the application of the Modified SeldingerTechnique and the insertion of a vascular sheath, inserting a generaluse guidewire into an antecubital vein 18 and then passing a vascularcatheter 40, per embodiments of the invention, over the guidewire. Thevascular catheter 40 is then passed up the vascular system to a jugularvein 14, or a subclavian 16 vein, or any other central vein. Theprocedure thus generally follows the steps depicted in FIGS. 2-5, exceptfor the entry through the antecubital vein rather than the femoral vein.After the moment depicted in FIG. 8, the remainder of this methodembodiment typically proceeds in accordance with the previouslydescribed embodiments of the present invention, as shown, for example,in FIGS. 6A-6D.

As has been noted in the description focused on embodiments of themethod of transvascular retrograde access placement, the presentinvention also provides systems, devices and device features, some ofwhich will now be described in greater detail. One such device, as shownin FIG. 9A, for performing transvascular retrograde access placement ina vessel of a patient may include a catheter 40 having an angled tip 42,a handle 49 coupled to the catheter, and a slider 46 coupled to thehandle. The handle has a reference portion 56. As shown, the position ofthe reference portion with respect to the handle indicates the positionof the angled tip 42 with respect to the handle. The handle alsoincludes a locking mechanism that is sized and configured to couple to aneedle tipped guidewire (not shown), such as the guidewire 50 shown inFIG. 5. The slider 46 is sized and configured to advance the needletipped guidewire through the catheter 40. The device may be designed asa one-time-use disposable device. Alternatively, the device may beconfigured to be re-sterilized. The device may be distributed in asterile barrier, such as Tyvek® or similar.

As shown in FIGS. 5 and 9A, the catheter 40 has an angled tip 42, and issized and configured to guide a needle tipped guidewire 50 to thedesired exit site on the wall of the central blood vessel (such asjugular vein 14). Embodiments of the inventive angled-tip vascularcatheter 40 are typically a 5 F catheter, but may be a 4 F catheter, oranother similarly sized and configured catheter. Embodiments of avascular catheter 40 generally measure about 90 to 100 centimeters inlength and include or support an angled-tip 42 that is typically angledat about 45 degrees from the axis of the vascular catheter 40 and isabout 1.5 centimeters in length. Alternatively, as shown in FIG. 9A, theangled-tip 42 that is typically angled at about 55 to 75 degrees fromthe axis of the vascular catheter 40. Vascular catheter 40 may furtherinclude a lubricious coating on its inner and/or outer surfaces. Thecatheter has a lumen disposed along the length of the catheter. Theinner diameter of the catheter may be 0.02″ to 0.08″. For example, theinner diameter of the catheter may be 0.047″, or any other suitabledimension. The catheter may be sized and configured to be placed overand/or advanced over a general use guidewire 30, as shown in FIG. 5.Additionally or alternatively, the catheter may be sized and configuredto be compatible with a general use femoral introducer sheath.Furthermore, the catheter may be designed to be used in a standardcatheter lab under fluoroscopy or other visualization mechanism.

As shown in FIGS. 4, 5, and 9A, the handle 49 is coupled to the catheter40 and facilitates the insertion of the catheter 40 and the needletipped guidewire 50. The handle has a lumen disposed along the length ofthe handle that is along the axis of the lumen of the catheter 40. Theinner diameter of the handle may be 0.01″ to 0.07″. For example, theinner diameter of the handle may be 0.038″, or any other suitabledimension. The lumen of the handle may be smaller than the lumen of thecatheter 40 to facilitate the insertion and the guidance of a needletipped guidewire into the handle and catheter. The handle is sized andconfigured to be held in a hand or hands of a user and manipulated tomove the catheter 40 and/or a needle tipped guidewire within thecatheter within a vessel of a patient. For example, the handle may be 5to 8″ long, such as 7.75″ long, or any other suitable length.

As shown in FIGS. 9B and 9C, the handle includes several features thatprovide for safe, accurate, and controlled movement of the vasculardevice and/or the needle tipped guidewire through the vessels of apatient and through the desired exit location from the vessel. Thehandle 49 includes a reference portion 56, a slider 46, a groove 48 inwhich the slider moves from a proximal position (as shown in FIG. 9B) toa distal position (as shown in FIG. 9A), and a locking mechanism 44. Forexample, the handle, by way of the reference portion 56, facilitatesaccurately positioning the angled catheter tip 42, into a desiredposition within a vessel, as shown in FIG. 4. Furthermore, once theangled catheter tip 42 is positioned accurately within the vessel, thefeatures of the handle (such as the slider 46, groove 48, and lockingmechanism 44) facilitate the controlled, accurate movement of a needletipped guidewire 50 through the catheter 40 and through the vessel, suchthat the needle tipped guidewire may exit the vessel in a safe andcontrolled manner, as shown in FIGS. 5 and 7D.

As shown in FIG. 9B, the handle includes a reference portion 56. Asshown, the reference portion may be a tab or otherwise raised portion ofthe handle. Alternatively, the reference portion may be a surfacefeature such as an indent, a color, or any other suitable indicia. Theposition and/or orientation of the reference portion 56 with respect tothe handle 49 indicates the position and/or orientation of the angledtip 42 with respect to the handle 49. For example, as shown in FIG. 9A,the reference portion may be on the same side of the handle as theangled tip of the catheter. As shown in FIG. 7D, once the catheter isinserted into the vessel, the handle 49 may be rotated such that thereference position 56 is moved to the desired position, therebyaccurately moving the angled tip of the catheter to a desired position,such as pointing toward the exit site 25 of the vessel.

As shown in FIG. 9C, the handle includes a locking mechanism 44. Thelocking mechanism is coupled to the handle and is sized and configuredto couple to a needle tipped guidewire. As shown, the locking mechanismmay include a collet 62 that is placed within the proximal end of thehandle 49 and a torque cap 58 which is placed over the collet 62 andcoupled to the distal end of the handle 49 via screw grooves 47. Thetorque cap 58 may be threaded onto the handle, or coupled to the handlein any other suitable fashion. In some embodiments, the torque cap 58includes wing(s) 64 that facilitate the tightening and loosening of thetorque cap 58 and locking mechanism 44. As the torque cap 58 istightened, it tightens the collet 62, which may then tighten around aneedle tipped guidewire to secure the needle tipped guidewire within thehandle. In alternative embodiments, the locking mechanism mayalternatively include any other suitable locking mechanism such as alever mechanism, cam mechanism, clamp mechanism, or any other suitablemechanism.

As shown in FIG. 4, as the catheter 40 and handle 49 are advanced over ageneral use guidewire 30, the locking mechanism may be loosened to allowthe handle to slide over the guidewire. In some embodiments, the lockingmechanism (or a portion thereof) may be removed from the handle to allowthe handle to slide over the guidewire. Once the catheter and the handleare in place, as shown in FIG. 4, the guidewire may then be removed.Once the guidewire has been removed, the locking mechanism may bereplaced back onto the handle and/or tightened onto the handle, suchthat the handle and locking mechanism may receive a needle tippedguidewire 50, as shown in FIG. 10A.

As shown in FIG. 10A, the handle 49 and locking mechanism 44 may receivea needle tipped guidewire 50. The needle tipped guidewire 50 may then beadvanced through the handle 49 and the catheter 40 to a desiredposition. Once in the desired position, the locking mechanism 44 maysecure the needle tipped guidewire 50 to a slider 46 disposed within thehandle. As described in more detail below, and as shown in FIG. 10, theslider 46 is in the proximal position within a groove 48 in the handlewhen the locking mechanism 44 is tightened around the needle tippedguidewire to provide the maximum advancement of the needle tippedguidewire 50 by the slider 46.

As shown in FIG. 5, the needle tipped guidewire 50 may be inserted intothe handle 49 and catheter 40. The needle tipped guidewire may beadvanced to a position, such as to the beginning (proximal end) of theangled tip. Once the needle tipped guidewire has been advanced, thelocking mechanism 44 may be tightened to secure the needle tippedguidewire to the slider 46 within the handle 49. The needle tippedguidewire 50 may then be advanced from the catheter 40 through thedesired exit site on the wall of the central blood vessel and skin ofthe patient, as shown in FIG. 5, by using the slider as described below.Prior to advancing the needle tipped guidewire from the catheter 40, theposition of the angled tip 42 of the catheter may be verified by theposition of the reference portion of the handle. Once the needle tippedguidewire 50 has exited the skin of the patient, the locking mechanismmay be loosened such that the device may be removed from the patientwhile leaving the needle tipped guidewire in place.

As shown in FIGS. 9A and 9B, the handle includes a slider 48 and agroove 48 in which the slider moves from a proximal position (as shownin FIG. 9B) to a distal position (as shown in FIG. 9A). As shown, inFIG. 10B, the slider may be sized and configured to receive a thumb orother digit of a user's fingers and may be moved proximally and/ordistally within the groove 48 by a user. The groove 48 may provide 5 to10 cm of travel for the slider, for example, the groove may allow for 6cm of travel of the slider within the handle.

As described above, the needle tipped guidewire may be advanced to adesired position within the catheter, and the locking mechanism 44 maybe tightened to secure the needle tipped guidewire to the slider 46within the handle. The needle tipped guidewire 50 may then be advancedfrom the catheter 40 through the desired exit site on the wall of thecentral blood vessel and skin of the patient, as shown in FIG. 5, byusing the slider. The slider functions to advance the needle tippedguidewire through the vessel and through the skin of a patient in acontrolled manner. In one example, the needle tipped guidewire may beadvanced manually or by any suitable means to a desired position withinthe catheter, such as to the proximal or beginning end of the angledtip. Once there, the locking mechanism may be tightened to secure theneedle tipped guidewire within the catheter and to secure the slidermechanism to the needle tipped guidewire. As shown in FIG. 10A, thelocking mechanism 44 is secured to the needle tipped guidewire 50 whilethe slider 46 is in the proximal position. Once the needle tippedguidewire is secured, the slider can be advanced to the distal position,as shown in FIG. 10B, thereby advancing the needle tipped guidewire 50through the catheter 40. If the slider is advanced all the way to thedistal position and the needle tipped guidewire has not beensufficiently advanced through the catheter, for example, the needletipped guidewire has not yet penetrated the vessel and/or the skin ofthe patient, the locking mechanism may be loosened and the slider may berepositioned to the proximal position. Once the slider has been returnedto the proximal position, the locking mechanism may be tightened again.Once the locking mechanism has been retightened, the slider may onceagain be advanced toward the distal position thereby advancing theneedle tipped guidewire further through the catheter. These steps may berepeated until the needle tipped guidewire has been successfullyadvanced out of the catheter, through the vessel wall and out of theskin of the patient.

A shown in FIGS. 11 and 10A-10B, a system for performing transvascularretrograde access placement in a vessel of a patient may include, inaddition to a vascular device as described above, a needle tippedguidewire 50 comprising a sharpened tip 52, wherein the needle is sizedand configured to pass through a desired exit site on the wall of thecentral blood vessel and skin of the patient. In some embodiments, theneedle tipped guidewire may have an outer diameter of 0.035″ or anyother suitable diameter. The needle tipped guidewire 50 may be 180 to220 cm in length. For example, the needle tipped guidewire may be 180 cmin length. Alternatively, the needle tipped guidewire may be anysuitable length to be advance from a vessel insertion point to the exitpoint. For example, a needle tipped guidewire used in an antecubitalvein, as shown in FIG. 8, may be shorter than a needle tipped guidewiresized and configured for insertion into a femoral vein, as shown in FIG.5. As shown, the needle tipped guidewire 50 includes a sharpened tip 52that facilitates passing the needle tipped guidewire through the desiredexit site on the wall of the central blood vessel and skin of thepatient. For example, the tip 52 may be a conical tip or any othersuitable geometry with a penetrating tip. The sharpened tip may be ofany suitable length. For example, the tip 52 may have a length of 0.075″to 0.095″, such as 0.085″ or any other suitable length. In someembodiments, the needle tipped guidewire may have a surface finish suchas a black oxide, or any other suitable finish to facilitate passingthrough a desired exit site on the wall of the central blood vessel andskin of the patient.

FIGS. 12A-12D show another embodiment of a transvascular retrogradeaccess system according to this invention. The system 100 includes acatheter 102 and an actuation handle 104. A piercing wire 106 extendsfrom a piercing wire push cap 108 through a luer lock 110 into andthrough handle 104 to the distal end of catheter 102. The distal tip 112of piercing wire 106 is sharp, like a needle, as shown in FIG. 12D. Anoptional radiopaque marker band 114 may be disposed at or near thedistal tip of catheter 102.

Actuation handle 102 may be used to bend the distal end of catheter 102.In the configuration shown in FIGS. 12A-D, the distal end of catheter102 is unbent. A catheter tip deflection actuator 116 of handle 104 maybe rotated about the handle's longitudinal axis to bend the distal endof catheter 102, such as to one or more preset angles, e.g., 45 degreesor 60 degrees. Handle 104 may be provided with indicators 117 showingthe amount of tip deflection. Deflection of the catheter tip may beaccomplished by using a steering wire running from the handle throughthe catheter, as is known in the art.

A collar 118 is attached to the piercing wire 106 within handle 104, anda spring 120 is disposed within the handle proximal to the collar. Inthe position shown in FIG. 12C, collar 118 holds spring 120 in acompressed configuration. A deployment button 122 extends into handle104 to hold collar 118 and spring 120 in this configuration, and anoptional safety slider 124 in the position shown in FIG. 12C acts as asafety interlock to prevent button 122 from being depressedinadvertently. Movement of slider 124 proximally permits button 122 tobe depressed against the action of optional button springs 126 to anactuation position that permits spring 120 to expand and push collar 118and piercing wire 106 distally. A detent 128 may be provided in handle104 to interact with slider 124 as it moves proximally.

A second optional safety feature is an interlock that prevents actuationof the piercing wire unless the catheter tip has been deflected.

Unless defined otherwise, all technical terms used herein have the samemeanings as commonly understood by one of ordinary skill in the art ofvascular catheterization. Specific methods, devices, and materials aredescribed in this application, but any methods and materials similar orequivalent to those described herein can be used in the practice of thepresent invention. While embodiments of the invention have beendescribed in some detail and by way of exemplary illustrations, suchillustration is for purposes of clarity of understanding only, and isnot intended to be limiting. Various terms have been used in thedescription to convey an understanding of the invention; it will beunderstood that the meaning of these various terms extends to commonlinguistic or grammatical variations or forms thereof. Moreover, any oneor more features of any embodiment of the invention can be combined withany one or more a features of any other embodiment of the invention,without departing from the scope of the invention. Still further, itshould be understood that the invention is not limited to theembodiments that have been set forth for purposes of exemplification,but is to be defined only by a fair reading of claims that are appendedto the patent application, including the full range of equivalency towhich each element thereof is entitled.

What is claimed is:
 1. A method of providing transvascular retrogradeaccess to a central blood vessel of a patient, the method comprising:inserting a distal end of a catheter into a blood vessel other than thecentral blood vessel, a proximal end of the catheter being connected toa handle disposed outside of the patient; advancing the distal end ofthe catheter into the central blood vessel; orienting the distal end ofthe catheter to an exit location within the central blood vessel;actuating a tissue piercer actuator of the handle to advance a tissuepiercing element from the catheter through the central blood vessel atthe exit location; introducing a device over the tissue piercing elementthrough the exit location into the central blood vessel; and whereinactuating the tissue piercer actuator comprises releasing a springwithin the handle, further comprising actuating a spring release elementto release the spring.
 2. The method of claim 1 wherein orientingcomprises rotating the catheter with respect to the patient.
 3. Themethod of claim 2 wherein rotating comprises rotating the handle andcatheter together.
 4. The method of claim 1 wherein orienting comprisesbending the distal end of the catheter with respect to a longitudinalaxis of the catheter.
 5. The method of claim 4 wherein bending comprisesmoving a bending actuator of the handle.
 6. The method of claim 4further comprising preventing actuation of the tissue piercer actuatorif catheter distal end is not bent.
 7. The method of claim 1 furthercomprising changing an interlock from a first state to a second state topermit the tissue piercer actuator to be actuated.
 8. The method ofclaim 1 further comprising locking the tissue piercing element to thetissue piercer actuator prior to actuating the tissue piercing actuator.9. A method of providing transvascular retrograde access to a centralblood vessel of a patient, the method comprising: inserting a distal endof a catheter into a blood vessel other than the central blood vessel, aproximal end of the catheter being connected to a handle disposedoutside of the patient; advancing the distal end of the catheter intothe central blood vessel; orienting the distal end of the catheter to anexit location within the central blood vessel; actuating a tissuepiercer actuator of the handle by releasing a spring within the handleto advance a tissue piercing element from the catheter through thecentral blood vessel at the exit location; and introducing a device overthe tissue piercing element through the exit location into the centralblood vessel.
 10. The method of claim 9 wherein orienting comprisesrotating the catheter with respect to the patient.
 11. The method ofclaim 10 wherein rotating comprises rotating the handle and cathetertogether.
 12. The method of claim 9 wherein orienting comprises bendingthe distal end of the catheter with respect to a longitudinal axis ofthe catheter.
 13. The method of claim 12 wherein bending comprisesmoving a bending actuator of the handle.
 14. The method of claim 12further comprising preventing actuation of the tissue piercer actuatorif catheter distal end is not bent.
 15. The method of claim 9 furthercomprising changing an interlock from a first state to a second state topermit the tissue piercer actuator to be actuated.
 16. The method ofclaim 9 further comprising locking the tissue piercing element to thetissue piercer actuator prior to actuating the tissue piercing actuator.